CPR FOR ADULTS

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Plan

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Definition/Aim of Cardiopulmonary Resuscitation (CPR)

Treatment of VF / Pulseless VT

Treatment of non-VF/VT rhythm

Potential reversible causes of cardiac arrest

Airway, IV Access, Drugs

Cardiopulmonary Resuscitation(CPR) - Definition

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Emergent medical applications that are performed for a livingwhose respiratory and circulation functions have been stopped

in an immediate and unexpected status

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To provide adequate amount of oxygenated blood

for vital organs

Cardiopulmonary Resuscitation(CPR) - Aim

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Cardiopulmonary Arrest (CPR)

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Causes: Airway obstruction

Respiratory distress

Cardiac abnormalities

ACUTE MYOCARDIAL INFARCTON

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CPR – ILCOR (International Liaison Committee On Resuscitation)

American Heart Association (AHA) European Resuscitation Council (ERC) Heart and Stroke Foundation of Canada (HSFC) Australian Resuscitation Council (ARC) Resuscitation Councils of Southern Africa (RCSA) Council of Latin America for Resuscitation (CLAR)

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CPR Basic Life Support

Advanced Life Support

Prolonged Life Support

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CPR Basic Life Support

Advanced Life Support

Prolonged Life Support

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CPR 30:2

Until defibrillator/monitor attached

Assess

Rhythm

Shockable

(VF/Pulseless VT)

Non-shockable

(PEA/Asystole)

1 Shock150-360 J biphasic

or 360 J monophasic

Open Airway Look for signs of life

Immediately resume

CPR 30:2

for 2 min

Call

Resuscitation

Team

During CPR:• Correct reversible causes• Check electrode position andcontact• Attempt / verify:

IV accessairway and oxygen

• Give uninterruptedcompressions when airway secure• Give adrenaline every 3-5 min• Consider: amiodarone,

atropine,magnesium

Immediately resume

CPR 30:2

for 2 min

Adult ALSAlgorithm

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CPR 30:2

Until defibrillator/monitor attached

Assess

Rhythm

Shockable

(VF/Pulseless VT)

Non-shockable

(PEA/Asystole)

1 Shock150-360 J biphasic

or 360 J monophasic

Open Airway Look for signs of life

Immediately resume

CPR 30:2

for 2 min

Call

Resuscitation

Team

During CPR:• Correct reversible causes• Check electrode position andcontact• Attempt / verify:

IV accessairway and oxygen

• Give uninterruptedcompressions when airway

secure• Give adrenaline every 3-5 min• Consider: amiodarone,

magnesium

Immediately resume

CPR 30:2

for 2 min

Adult ALSAlgorithm

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Open Airway Look for signs of life

…. to confirm cardiac arrest

Patient response

Open airway

Check for normal breathing

(caution agonal breathing)

Check circulation

Monitoring

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CPR 30:2

Until defibrillator/monitor attached

Assess

Rhythm

Shockable

(VF/Pulseless VT)

Non-shockable

(PEA/Asystole)

1 Shock150-360 J biphasic

or 360 J monophasic

Open Airway Look for signs of life

Immediately resume

CPR 30:2

for 2 min

Call

Resuscitation

Team

During CPR:• Correct reversible causes• Check electrode position andcontact• Attempt / verify:

IV accessairway and oxygen

• Give uninterruptedcompressions when airway

secure• Give adrenaline every 3-5 min• Consider: amiodarone,

magnesium

Immediately resume

CPR 30:2

for 2 min

Adult ALSAlgorithm

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Open Airway Look for signs of life

Call Resuscitation Team

Cardiac arrest confirmed

CPR 30:2Until defibrillator / monitor attached

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Chest Compression

30:2

Compressions

Centre of chest

5-6 cm depth

100-120 min-1

Uninterrupted compressions when airway secured

Avoid

Provider fatigue

Interruptions

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CPR 30:2

Until defibrillator/monitor attached

Assess

Rhythm

Shockable

(VF/Pulseless VT)

Non-shockable

(PEA/Asystole)

1 Shock150-360 J biphasic

or 360 J monophasic

Open Airway Look for signs of life

Immediately resume

CPR 30:2

for 2 min

Call

Resuscitation

Team

During CPR:• Correct reversible causes• Check electrode position andcontact• Attempt / verify:

IV accessairway and oxygen

• Give uninterruptedcompressions when airway

secure• Give adrenaline every 3-5 min• Consider: amiodarone, atropine,

magnesium

Immediately resume

CPR 30:2

for 2 min

Adult ALSAlgorithm

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Adult ALSAlgorithm

Open Airway Look for signs of life

Call Resuscitation Team

CPR 30:2Until defibrillator/monitor attached

AssessRhythm

Shockable(VF/Pulseless VT)

Non-shockable(PEA/Asystole)

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Adult ALSAlgorithm

Open Airway Look for signs of life

Call Resuscitation Team

CPR 30:2Until defibrillator/monitor attached

AssessRhythm

Shockable(VF/Pulseless VT)

Non-shockable(PEA/Asystole)

CARDİAC ARREST RHYTHMS

1. Ventricular Fibrillation (VF)2. Pulseless Ventricular Tachicardia (VF)3. Asystole4. Pulseless Electrical Activity (PEA)

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Shockable (VF)

Irregular waveform

No recognisable QRS complexes

Random frequency and amplitude

Uncoordinated electrical activity

Coarse /fine

Exclude artifact

movement

electrical interference

Monomorphic VT

broad complex rhythm

rapid rate

constant QRS morphology

Polymorphic VT

torsade de pointes

Shockable (VT)

Precordial Thump

Rapid treatment of a witnessed and monitored VF/VT cardiac arrest

Used if defibrillator not immediately available?

1st shock 150 - 200 J biphasic 360 J monophasic

AssessRhythm

Shockable

(VF/Pulseless VT)

1 Shock150-360 J biphasic

or 360 J monophasic

Immediately resumeCPR 30:2 for 2 min

Defibrillation Energies

Vary with manufacturer

Check local equipment

If unsure, deliver 200 J (do not delay shock)

Deliver 2nd shock

Deliver 3rd shock

CPR for 2 min

If VF/VT persists

CPR for 2 min

Deliver 4th shock

Adrenalin, 1mg iVAmiodaron, 300 mg

2nd and subsequent shocks

Max. (270-360J) biphasic

360 J monophasic

Minimise delays between CPR

and shocks (< 10 s)

After delivery of shock

Continue CPR for another 2 min stop CPR only if patient shows signs of life

After 2 min, assess rhythm:

If organised electrical activity, check for signs of life: if ROSC start post resuscitation care

if no ROSC go to non VF/VT algorithm

If asystole, go to non VF/VT algorithm

AsystolePulseless Electrical Activity (PEA)

AssessRhythm

Non-shockable(PEA/Asystole)

Immediately resume

CPR 30:2 for 2 min

Absent ventricular (QRS) activity

Atrial activity (P waves) may persist

Rarely a straight line trace

Treat fine VF as asystole

Non-shockable(Asystole)

AsystoleDuring CPR:

check leads are attached

adrenaline 1 mg IV every 3 – 5 min

Clinical features of cardiac arrest

ECG normally associated with an output

Non-shockable(PEA)

Pulseless Electrical Activity(PEA)

Exclude/treat reversible causes

Adrenaline 1 mg IV every 3-5 min

During CPR: Correct reversible causes Check electrode position and contact Attempt / verify:

- IV access- Airway and oxygen

Give uninterrupted compressions when airway secure

Give adrenaline every 3-5 min Consider: amiodarone, magnesium

Potential reversible causes: Hypoxia Hypovolaemia Hypo/hyperkalaemia & metabolic disorders Hypothermia

Tension pneumothorax Tamponade, cardiac Toxins Thrombosis (coronary or pulmonary)

4H

4T

Airway and Ventilation

Secure airway: tracheal tube

supraglottic airway device

e.g. LMA

Once airway secured, if possible, do not interrupt chest compressions for ventilation

Avoid hyperventilation

Intravenous Access

Peripheral versus central veins

Intraosseous Access

TRACHEAL ACCESSx

Drugs

Adrenaline

Amiodarone

Magnesium

Thrombolytics

Sodium bicarbonate

O2

AdrenalineActions:

agonist arterial vasoconstriction

systemic vascular resistance

cerebral and coronary blood flow

agonist heart rate

force of contraction

myocardial O2 demand

(may increase ischaemia)

Adrenaline

Indications:

During cardiac arrest VF/VT – give after 3rd shock

Non VF/VT – give immediately

Repeat every 3-5 min

1 mg IV

Cautious use after ROSC

Amiodarone

Actions:

Lengthens duration of action potential

Prolongs QT interval

Mild negative inotrope - may cause hypotension

AmiodaroneIndications: Shock refractory VF/VT

300 mg IV

Give after 3rd shock

If unavailable give lidocaine 1.5mg/kg IV

Atropine

Actions:

Blocks effects of vagus nerve

Increases sinus node automaticity

Increases atrioventricular conduction

AtropineIndications:

Peri-arrest Symptomatic sinus, atrial or nodal bradycardia

500 mcg IV increments to 3 mg

Magnesium

Hypomagnesaemia often co-exists with hypokalaemia

Actions:

Depresses neurological and myocardial function

A physiological calcium blocker

MagnesiumIndications:

VF / VT with hypomagnesaemia

Torsade de pointes

Atrial fibrillation

Digoxin toxicity

Dose: cardiac arrest 2 g (8 mmol) IV bolus

peri-arrest 2 g (8 mmol) IV over 10 min

Thrombolytic Drugs

Actions:

Dissolves thrombus

Improves cerebral blood flow

Has a role in coronary thrombosis and pulmonary embolism

Thrombolytic Drugs

Indications: Cardiac arrest caused by suspected pulmonary

embolus Can take up to 60 min to have effect

Dose: Tenecteplase 500-600 mcg kg-1 IV over 10 sec Alteplase (rt-PA) 10 mg IV over 1-2 min followed

by IV infusion of 90 mg over 2 h

Sodium Bicarbonate

Actions:

Alkalinising agent (increases pH)

But can:

increase carbon dioxide load

inhibit release of oxygen to tissues

impair myocardial contractility

cause hypernatraemia

Sodium Bicarbonate

Indications:

Life-threatening hyperkalaemia

Tricyclic overdose

Severe metabolic acidosis (pH < 7.1)

Dose: 50 ml 8.4% sodium bicarbonate IV

Summary

• ALS algorhythm provides a standardised approach to

cardiac arrest treatment

• Shockable rhythms (VF/pulseless VT)

• Non-shockable rhythms (Asystole, PEA)

• Reversible reasons of cardiac arrest (4H,4T)

LAST WORDS

Drugs role in cardiac arrest becomes after effective chest compression, effective ventilation with high oxygen concentration and defibrillation

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THANK

YOU…

Dr. Sule AKIN

54

THANK

YOU…

Dr. Sule AKIN